While the opportunities to improve patient care outcomes and cost-effectiveness within the U.S. healthcare system through the development of various types of accountable care organizations (ACOs) are robust and multidimensional, so, too, are the cultural, process, strategic, and technological challenges, industry experts agree.
That complex picture emerged clearly during a breakout session Wednesday at the World Health Care Congress + Exhibition, being held at the Marriott Wardman Park Hotel in Washington, DC. The panel discussion was moderated by Lindsay Dunn, an editor at Health Forum, a division of the American Hospital Association. The other panelists were Barbara Adams, vice president of innovative technology services at Texas Health Resources (Arlington); Adam Wilcox, director of healthcare informatics at Intermountain Healthcare (Salt Lake City); Scott Berkowitz, M.D., medical director, accountable care, at Johns Hopkins Medicine (Baltimore); and Benjamin Zaniello, M.D., director of medical population health informatics at the Seattle-based Providence Health & Services.
Asked what elements are truly foundational in terms of laying the IT foundation for accountable care, Texas Health Resources’ Adams said, “I’ve spoken often about this. There are four building blocks in our world. The first one,” Adams said, “is the EMR [electronic medical record] That really is ‘table stakes’ right now. The second is a data warehouse. We don’t have the luxury of having all of our providers on a single EMR, and in that regard, we really rely on our data warehouse. The third one,” she said, “is a set of analytical tools—dashboards, BI [business intelligence], and so on. And the fourth element, which we haven’t fully implemented yet—is population management, which encompasses outreach campaigns, and efforts to close gaps in care.”
Asked how he and his colleagues make decisions about which data sets to use to support clinical decision support at the point of care, versus which data sets to use to support broad, strategically focused, system-wide analytics, Johns Hopkins Medicine’s Berkowitz said, “We’re still in the developmental phase. But we use the data in a lot of different ways, first of all, in terms of executing on care management interventions. We determine who the high-risk members of the population are, and we bring in the care managers in real time,” Berkowitz reported.
“We’re trying to develop expertise in terms of determining who the patients in our population are who do not have primary care,” he continued. “In fact, in an academic medical center environment, a lot of patients are actually attributed to us through specialists. We’re also doing dashboarding,” he said, and added that “We provide registry information to physicians, high-risk patient lists. There are certain things we’re able to do in real-time,” he said, while some processes are not yet “real-time.” When truly real-time sharing isn’t possible, he said, “We’re focusing on quickly collecting information and sharing it after the fact.”
Different Needs in Different Types of ACOs
Does it actually matter exactly how patient care organizations manage and share data that relates to different ACO ventures they’re involved in? Yes, absolutely, Texas Health Resources’ Adams said. “Yes—you need to build a crosswalk of your different ACO measures,” she said, “because once you do that, build a bridge, you can reference back to which measures you’re reporting on. It’s not one set of reports that goes to the payers, it’s different reports involving numerous different measures.”
Given the fact that nearly every patient care organization involved in ACO-type and risk-based contracts is working with multiple payers, Dunn asked, how can physicians gain competency and fluency in working with many different sets of data from numerous different initiatives or programs?
“That’s a real challenge,” Hopkins Medicine’s Berkowitz said, noting that “It’s not even just measures” that are involved when a patient care organization is involved in multiple risk-based contracts that require active case management; “it’s interventions, and knowing what support might be needed for certain payer lines. We are an all-payer state in Maryland, so we’re able to spread that [set of tasks and responsibilities], on the inpatient side, across some of our payer lines; but outpatient, it’s different. I’m a cardiologist,” Berkowitz noted; “but for primary care docs, especially, it can be very challenging. We try very hard to create measure sets and dashboards. There are more similarities than differences between and among these programs,” he added, “and I try to emphasize that. But making sure products can get to the sites of care effectively, and maximizing resources—it’s a challenge to help the physicians and providers.”
What’s more, Texas Health Resources’ Adams noted, when one gets down to granular levels of operations, things becoming even more challenging in ways. “We’ve found that between the different payers, the ranges [around performance, even on the same measures] were different,” she reported. “For example,” she said, “I still needed my docs to document for tobacco cessation advisement or hemoglobin a1c levels. But,” she said, given all the different levels of performance associated with the same measures, but in contracts with different payers, “I had our docs meet the measures at the highest level, to meet all the requirements of the different payers.”
Intermountain’s Wilcox offered a slightly different perspective on the subject. “For us, I don’t know so much that it’s meeting the highest measures strategy, but rather, because of the alignment created with providers through the management of our own plan, we’ve been the most aggressive within our own plan. And so we’ve focused on the areas where we have the highest alignment. We’re better aligned with that group, and can be most aggressive with those measures. And we negotiate up to that level as we can, with other payers.”
In other words, he continued, “I think it’s important to demonstrate where you have the most alignment, and then require the highest levels of meeting the requirements of those measures. And our salaried physicians are the ones where we can demonstrate what is most possible, and then we try to do the best we can with affiliated physicians, etc.”
Meanwhile, Providence’s Zaniello said that, “For us, it’s to keep it as simple as possible. Primary care physicians have so much on their minds, and medicine is so complex, that to give them different ranges, simply makes the whole thing too complex.” At Providence, he said, “We first needed to educate them that they would be measured based on working with us on risk—just getting care providers aware that this is a managed risk patient, not a fee-for-service patient, was an important first step. It means a different sort of care, and hopefully, a better sort of care, but in the long term, just getting them to understand that this patient drives your compensation, has been a challenge.”
What’s more, Intermountain’s Wilcox noted that, “If we can get to the point where the clinicians are using the data in their workflow, which isn’t happening yet now, or that patients use patient portals, which they’re not yet doing,” he and his colleagues could really accelerate progress in terms of physicians making real clinical practice changes based on receiving and understanding clinical data and their performance on outcomes measures. “We can’t rely on transcription or patient portals,” he added, so we’ve got to find some way to build it into the workflow.”
Hopkins Medicine’s Berkowitz emphasized the cultural and process aspects of all this data-driven clinical performance work. “I think that how we communicate with our provider community is absolutely critical,” he said. Whether it’s how you share data, or just how you message with them on the big picture—and that you then empower them with tools—how you approach them is very important. With respect to dashboarding, we are trying to have quality and utilization measures within a common dashboard we’re building together, with performance improvement plans, with “easy solutions”—sometimes it’s a matter of data capture, sometimes, CDS, sometimes explaining to them what they can do. Some efforts are global across the ACO, and in some cases, we’re trying to empower practice leadership, medical directors, practice leaders,” he said. Part of the challenge, he added, is that “We hear different things form doctors. Some say, we’re trying to do better; but sometimes, some say it’s too much.”
Importantly, he said, “We’re trying to help them over time. We’re also about to launch a provider newsletter—it might focus on educating around one outcomes measure of the month, maybe a choosing wisely of the month. We’ve already created regional forums where providers tell us what they need and what they don’t’ have,” he added. “And what they need really varies by community, across our health system.”